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Cuts and Scabs

A doctors’ strike could help save the United Kingdom’s National Health Service.

Saif Uddin / Flickr

The first week of this year saw barristers across England and Wales opting not to attend legal proceedings, bringing courts in major cities to a standstill. This was the first time they had engaged in industrial action since the bar was established 600 years ago. They were protesting the proposed 30% cuts to legal aid fees, which will result in reduced availability and quality of legal representation for the most vulnerable, and will endanger many jobs in the legal sector.

In March, criminal defense solicitors and probation staff followed suit, joining barristers in a 1000-person-strong second walk-out. Given the significant disruption to trials as a result of these actions, their resolve to protect the UK’s criminal justice system looks set to force government ministers to the negotiating table.

Meanwhile, as the National Health Service, the UK’s national public health system, undergoes the most dramatic overhaul since its conception, doctors continue to work in seeming oblivion. These reforms amount to large-scale cuts, job losses, privatization, reduced availability of treatment, and limited accountability to citizens.

If the free-at-point-of-use NHS is to remain a just and robust public health system, doctors need to take some cues from the barristers on the picket line. As cuts are made to vital services across the board, industrial actions, such as general strikes, taken by workers with relative job security and good pay, are the only way we can defend the availability of free, high-quality public services like universal healthcare.

Though their history of activism is disappointingly sparse, there was a glimmer of hope in 2012, when the British Medical Association called for a doctors’ strike over threatened changes to NHS pensions. We should be careful before claiming that doctors were striking “selfishly”: whatever the motivations of individuals, industrial action incurs a risk, normalizes resistance, and can empower other workers.

That said, the turn-out for the strike was a feeble 10%. This widespread scabbing seems to have caused little concern or division within the profession. Those too embarrassed to cite apathy or short-term self-interest as their reason for crossing picket lines may have put their non-participation down to pessimism, but conversations with doctors suggest that many default on wheeling out the over-used, and misunderstood, Hippocratic oath.

What are the ethics of a doctors’ strike? On the face of it, it seems as though withholding labor conflicts with the duty of providing medical care to those in need without being influenced by a personal or political agenda. This is often mistakenly equated to the Hippocratic oath, which then appears to rule out industrial action.

In fact, the Hippocratic oath itself has surprisingly little to do with modern medical care. For one, only around fifty percent of British medical students swear any kind of oath before beginning to practice. Those who do are committed to a diluted modern version which makes the nominal demand that they perform their job responsibly, but leaves out the archaic details of the original oath which, among other things, categorically forbade doctors from administering abortions.

Interestingly, though, the original text has doctors vow to “use treatments for the benefit of the ill in accordance with my ability and my judgment, but from what is to their harm and injustice I will keep them.”

Strike action demands that (at least some) doctors temporarily suspend their short-term duty of care with the aim of securing long-term gains; in this case, preserving the existence and quality of the NHS and the autonomy that trained medical professionals have in making decisions which prioritize patient safety and staff working conditions above the drive for profit.

On the face of it, it seems as though a strike requires doctors to suspend the concern about harm in pursuit of the more threatening injustice posed by NHS cuts. But would a strike actually harm patients? Studies indicate not. (And, just to be pedantic, it may lead to a temporary decrease in mortality because non-emergency high-risk surgery isn’t performed).

Certainly a strike would temporarily reduce the ability of hospitals to provide care to their patients, which is, of course, the very idea: strike action is predicated on the notion of bringing the machine to a halt so the machinists’ demands can be listened to in the wake of urgency that follows. This is unlikely to have serious consequences: remember that hospitals operate at reduced capacity during nights and weekends, with a handful of doctors covering several wards.

Sometimes, the efficacy of industrial action is as much about public perception as it is about genuine disruption. Even if, as I contend, the long-term effect on medical care would be imperceptible, the change in the urgency of public discourse concerning NHS reforms, and the threat of further (potentially more serious) actions would have the potential to precipitate rapid negotiations regarding the speed, extent, and details of the proposed reforms

On the other hand, will the NHS reforms harm patients? Unquestionably. It will be some time before the extent of the damage is seen. But unlike the controlled reorganization required to reduce activity within a hospital, as during a strike, the adverse effects of cuts and privatization cannot be predicted, regulated, or easily put right.

While the future of the NHS looks increasingly uncertain, lapses in quality have already been noted as the first phase of reforms are implemented. Hospital waiting lists are at a five-year high, with close to 3 million-long queues for treatment. No wonder, with accident and emergency department capacities reduced by 10% and 35,000 employees “made redundant,” including nearly 6,000 nurses.

A £20 billion saving drive by 2015 is tightening the purse strings to a noose. Worse, the conflict of interest is glaringly discomfiting: 20% of current Conservative members of parliament have financial links to individuals or companies related to private healthcare.

Doctors have considerably better job security than their fellow workers inside and outside the hospital, and, unlike nurses, paramedics, and front-line administrators, much of their work can be temporarily scaled back without impacting on patient care. They are therefore best placed to implement successful industrial action.

The 2012 doctors’ strike over pension reforms (rightly or wrongly) had Britons grumbling about high doctors’ salaries and the lack of decent pensions for the rest of us. Then-health secretary and architect of the current reforms Andrew Lansley was predictably quick off the mark in stirring such division; no doubt others would readily capitalize on the opportunity to deflect attention from, and therefore sabotage, doctors’ cause by exaggerating the risk to patients’ safety, emphasizing senior doctors’ substantial salaries, and rebranding the strike as an assault on the health-service rather than an affront to the government’s deconstruction of that service. Such tactics are part-and-parcel of the way in which governments and corporations undermine industrial action.

And their tactics work. People are critically dependent on public services, and are liable in that vulnerability to side with whichever party appears to want that service to resume operation as quickly as possible. Such was the unfortunate outcome of the New York City bus drivers’ strike in January this year, in which the drivers were successfully cast by their employers as being engaged in “a strike against our children.”

Doctors and their patients must remain vigilant to these tactics, and accept from the outset that certain inconvenient facts must be factored in intelligently-organized industrial action. First, given that only 10% of doctors were prepared to strike to protect their own pensions, doctors’ salaries will likely be matched in a privatized system, and that doctors’ incomes place them in a minority of the population for whom public health-care is not a necessity, we can expect some reluctance as regards taking action to defend the NHS.

Second, as we have seen, the government and media will summarily mischaracterize any action doctors do take, and will sensationalize the short-term impact on health-care as a scare tactic to stoke their own economic interests. Striking doctors have a duty to carefully explain the necessity of their proposed actions to members of the public and to other doctors; we all, in turn, must be prepared to defend them.

All that said, there is reason to believe a strike for the preservation of the NHS has uniquely high odds for success. The British public is fiercely proud of the NHS, and respects the doctors who work within. The public could feel obliged to confront the reality of the damage to the health service that leads doctors (with their limited history of industrial action) to resort to these measures.

Undoubtedly, fingers would start to be pointed at the government, which has so ruthlessly dismantled a service that didn’t need fixing, to close a deficit for which the NHS was not responsible.

The largely unspoken popular rhetoric that discourages doctors’ strikes on the basis of the Hippocratic oath is a willful misuse of ethics by politicians in order to prevent the only action which could confront their as-yet unchallenged commodification of the service.

The revised text of the UK Hippocratic oath, published by the BMA in 1997, makes a demand which seems primed for the current juncture:

I will use my training and professional standing to improve the community in which I work. I will treat patients equitably and support a fair and humane distribution of health resources. I will try to influence positively authorities whose policies harm public health.. . .
I will strive to change laws which are contrary to patients’ interests or to my professional ethics.

I suggest that we keep this clause in mind and object strongly to any claim that doctors should be exempt from their responsibilities as citizens, not least because we are lucky enough to have a health service that is, at its roots, a political structure, whose existence stems from a moral contention that healthcare should be universal and free.

Doctors as actors within that structure should acknowledge their moral duty; whether or not they were asked to swear an oath, they should abide by its spirit, for it sits at the heart of the rationale for their profession. Far from precluding industrial action, in the current situation, that spirit positively compels them to engage in it.

The surest way to honor the Hippocratic Oath is for doctors to intervene before their ability to effectively save lives diminishes under the compulsion to produce profit for private companies.

I therefore call on doctors to take action: to protect the free health service that is the UK’s greatest asset, to protect the jobs and working conditions of themselves and their colleagues, and to protect the fairness and the efficacy of the care they provide their patients. And as members of the public who are all ourselves patients at some points in our lives, it is our duty to educate, agitate, and pressure our own doctors to take action, to support them if and when they do, and to pressure the government so that their risks taken don’t amount to nothing.